MINI REVIEW

published: 22 April 2021

doi: 10.3389/fmed.2021.656926

Oral Mucosa, Saliva, and COVID-19

Infection in Oral Health Care
Devi Sewvandini Atukorallaya* and Ravindra K. Ratnayake
Department of Oral Biology, Dr. Gerald Niznick College of Dentistry, Rady Faculty of Health Sciences, University of Manitoba,
Winnipeg, MB, Canada

The SARS-CoV-2 virus has shaken the globe with an ongoing pandemic of COVID-19
and has set challenges to every corner of the modern health care setting. The oral
mucosa and saliva are high risk sites for higher viral loads and dental health care
professionals are considered a high risk group. COVID-19-induced oral lesions and loss
of taste and smell are common clinical complaints in the dental health care setting. The
SARS-CoV-2 virus has been found to cause a wide range of non-specific oral mucosal
lesions, but the specific diagnosis of these mucocutaneous lesions as COVID-19 lesions
will facilitate the prevention of SARS-CoV-2 in dental health care settings and aid in proper
patient management. The reported loss of taste and smell needs further investigation at
the receptor level as it will give new insights into SARS-CoV-2 pathogenicity. The high
yield of virus in the salivary secretion is a common finding in this infection and ongoing
Edited by:
Chaminda Jayampath Seneviratne,
research is focusing on developing saliva as a rapid diagnostic fluid in COVID-19. In
National Dental Center of this review, we discuss the significance of oral mucosa, saliva and the relevance of the
Singapore, Singapore
COVID-19 pandemic in dentistry.
Reviewed by:
Citra Fragrantia Theodorea, Keywords: oral epithelial cells, saliva, taste, SARS-CoV-2, ACE2 receptor, COVID-19
University of Indonesia, Indonesia
Shankargouda Patil,
Jazan University, Saudi Arabia INTRODUCTION
*Correspondence:
Devi Sewvandini Atukorallaya Coronavirus disease 2019 (COVID-19) is an infectious disease that was first detected in large
[email protected] numbers in Wuhan, China; it is caused by a newly discovered coronavirus identified as severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) (1). Coronaviruses are large RNA viruses with
Specialty section: beta coronaviruses, including SARS-CoV and SARS-CoV-2, having been shown to be the deadliest
This article was submitted to viruses, causing respiratory distress syndrome (2, 3). Since 1960, six coronaviruses have been found
Infectious Diseases - Surveillance, to cause diseases in humans. In 2002, SARS-CoV caused a major outbreak known as severe acute
Prevention and Treatment,
respiratory syndrome (SARS), which caused about 10,000 fatalities worldwide (4). Only a decade
a section of the journal
later, another pathogenic coronavirus, known as the Middle East respiratory syndrome coronavirus
Frontiers in Medicine
(MERS-CoV), caused an endemic in Middle Eastern countries (4, 5). SARS-CoV-2 is the seventh
Received: 21 January 2021
member of the coronavirus family to affect humans (4). Interestingly, the genome of SARS-CoV-2
Accepted: 04 March 2021
aligned with the genomes of viruses from bats (Bat-CoV and Bat-CoV RaTG13) in Rhinolophus
Published: 22 April 2021
affinis species of the Yunnan province with 96% similarity; structural analysis revealed a mutation
Citation:
in the envelope protein (Spike protein) and nucleocapsid protein (6). The coronavirus has a simple
Atukorallaya DS and Ratnayake RK
(2021) Oral Mucosa, Saliva, and
structure with few proteins (7). There are 4 major structural proteins: the envelope protein (E),
COVID-19 Infection in Oral Health spike protein (S), transmembrane protein (M), and nucleoprotein (N). The E, S, and M proteins
Care. Front. Med. 8:656926. facilitate virus entry into the host cells, virion assembly, and viral pathogenesis. The viral genome,
doi: 10.3389/fmed.2021.656926 is in close association with N protein and also aid the E protein in virion assembly (7).

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Atukorallaya and Ratnayake Oral Health and COVID-19

At present, two modes of transmission for SARS-CoV-2 oral microbiome, is a well-known site harboring various types
have been identified: direct and indirect transmission. Direct of respiratory viruses (22, 23). The oral saliva has been found to
transmission includes contact with the infected individual’s body contain a high yield of viruses, suggesting salivary glands as active
fluids, respiratory or salivary droplets and, other body fluids such proliferating sites for this virus (20, 24). Moreover, xerostomia
as feces, urine, semen, and tears (8). The signs and symptoms of and loss of taste can be associated with the salivary gland
COVID-19 can be divided into respiratory and extra-respiratory dysfunction associated with COVID-19 (23, 25). However, these
manifestations. The most common reported respiratory signs are signs are often masked by the more life threatening respiratory
cough, fever, and dyspnoea (9–11). There is a wide range of extra- signs and symptoms, which need emergency medical attention
respiratory signs and symptoms, including oral mucosal lesions most of the time. This review aimed to provide histological
and neurological dysfunctions, such as loss of smell, loss of taste, specifications of the oral mucosa and its functional significance in
headache, and associated myofascial pain; these are now included SARS-CoV-2 infection, highlighting the orofacial manifestations
in the diagnostic criteria of this disease (Table 1) (10, 19). and its impacts on the dental health profession.
The nasal cavity, nasopharynx, oropharynx and oral cavity
are identified as potential replication sites for the SARS-CoV-2 ORAL MUCOSA
virus (20, 21). The oral cavity, which is rich in saliva and the
The oral mucosa is the specialized mucous outer covering layer
of the oral cavity which consists of the stratified squamous
epithelium and the underlying connective tissue (lamina propria)
TABLE 1 | Orofacial manifestations of COVID-19. (Figure 1) (26). Apart from the common epithelial functions,
such as protection and lining, oral mucosa is regionally
Clinical features References
specialized to form special functions like taste perception, sensory
Headache (12–15)
perception, mastication, and secretion (26). The oral epithelial
cells have numerous structural and functional specifications to
Myofacial pain (13–15)
withstand physical and chemical attacks. Squamous epithelia
Oral ulcerations (14–16)
possess structural properties like stratification and cornification
Burning sensation of the (14, 16)
oral mucosa of the keratinocytes and specific cell-to-cell interactions to
Oral vesicle formation (16, 17)
maintain their barrier functions (26). The epithelial cells are
Loss of taste (14–16, 18)
metabolically active and are capable of reacting to external stimuli
Loss of smell (14–16, 18)
by synthesizing a number of cytokines, adhesion molecules,
Dry mouth (14, 15)
growth factors, and chemokines (27). The oral cavity is a
dynamic ecosystem that varies over time in ways that influence
Skin discomfort (16)
spatial patterns of microbial community assembly (28). Among

FIGURE 1 | Modified image indicating the location of the entry points of SARS-CoV-2 and the anterior view of the oral cavity labeling different areas of the oral
mucosa. (A) Blue arrows indicate the nasal and oral entrance of the virus. The location of the olfactory epithelium and taste buds (TB). Olfactory epithelium is located
on the roof of the nasal cavity. Taste buds can be found in the tongue, tonsils and oropharynx. (B) The specific location of the Stratified squamous keratinized
epithelium (SSKE) and Stratified squamous non keratinized epithelium (SSNKE) in the oral cavity. https://www.informedhealth.org/how-do-the-tonsils-work.html,
“How do the tonsils work?” Institute for Quality and Efficiency in Health Care (IQWiG, Germany), 17 Jan 2019.

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Atukorallaya and Ratnayake Oral Health and COVID-19

the oral microbial community are common commensals that of host immune reaction to the viral antigen (23). In the
can be opportunistic pathogens when the host immunity is oral mucosa, viral infections disrupt epithelial cells and trigger
compromised. There are many species of bacteria, fungi and local inflammatory reactions which typically present with abrupt
viruses which are either pathogenic or opportunistic, causing onset and the association of solitary or multiple blisters or
common oral diseases such as caries and periodontitis, oral ulcerations (23). Oral vesicles, blisters, macular popular rashes
candidiasis and viral mucosal infections (29, 30). and ulcerations are the common clinical features of viral
infections (23). In SARS-CoV-2, epithelial injury causes similar
pathogenic features in the oral tissues, such as ulcers, erosions,
PATHOGENESIS OF SARS-CoV-2 IN ORAL bullae, vesicles, pustules, fissured or depapillated tongue,
MUCOSA macule, papule, plaque, pigmentation, halitosis, whitish areas,
haemorrhagic crust, necrosis, petechiae, swelling, erythema,
Oral viral infections are a common clinical complaint in Kawasaki-like angular cheilitis, atypical Sweet syndrome, and
dentistry, which is often associated with oral mucosal lesions. Melkerson-Rosenthal syndrome (19, 25, 38). The most common
The herpes virus group (herpes simplex 1–8), human immune sites of involvement are the tongue (38%), labial mucosa (26%),
deficiency virus (HIV) and Zika virus are capable of infecting and palate (22%) (19, 39). Oral lesions were almost equal in both
and replicating in the oral mucosa, leading to painful oral genders (49% female and 51% male). Patients with an older age
ulcers (22, 27). Viruses like paramyxovirus, HIV, cytomegalovirus and higher severity of COVID-19 disease had more widespread
and Epstein-Barr virus (EBV) have been found to replicate in and severe oral lesions (25).
salivary glands and negatively affect the normal functioning of The histological analysis of oral SARS-CoV-2 lesions is
the salivary glands (22). Several recent reports have described the associated with defects in the vascular arrangement of the
oral manifestations of SARS-CoV-2 infection such as vesicular oral mucosa (40). Pathogenesis of oral mucosal lesion of
bullous lesions and ulceration (24, 25, 31). COVID-19 are associated with the accumulation of lymphocytes
The single cell RNA-seq (scRNA-Seq) studies of ACE2 and Langerhans cells in the vasculature of the subcutaneous
expression have detected high levels of expression in keratinized junctions and virus induce keratinocyte destruction by the
epithelial cell surfaces of the oral cavity, such as the dorsum cytotoxic lymphocytes (41). Histological examination of biopsies
of the tongue and hard palate, rather than buccal or gingival of COVID-19 patients who also had skin manifestations
tissues (32). In the human body, the ACE2 receptor is known confirmed the vascular ectasia with dilated capillaries, large
to be important in regulating blood pressure homeostasis by blood filled spaces and perivascular lymphocytic infiltrate with
regulating the renin–angiotensin–aldosterone system (RAAS), eosinophilia (40).
where it converts angiotensin I to angiotensin II; this cascades A lack of oral hygiene, opportunistic infections, stress,
body functions to maintain blood pressure and sodium water immunosuppression, vasculitis, and hyper-inflammatory
retention (33). SARS-CoV-2 enters a host’s body and invades response secondary to COVID-19 were found to be the
host cells via the ACE2 membrane receptor; this binding leads predisposing factors for the onset of oral lesions in COVID-19
to conformational changes and cleavage of the S protein from the patients (19, 39). Stress-induced oral ulceration can be increased
virion, and releases the nucleocapsid into the cytoplasm (7, 34). among patients due to the unknown fear of the pandemic.
The S protein is proteolytically cleaved by cellular cathepsin L It has been already reported that this pandemic has severely
and the transmembrane protease serine 2 (TMPRSS2) (33). Haga affected the mental health of the global community (42).
et al. found that SARS-CoV viruses can induce tissue necrosis Patients have reported changes in sensation in the tongue,
factor (TNF)-α-converting enzyme (TACE)-dependent shedding plaque-like changes in the tongue and swelling in the palate,
of the ectodomain of ACE2, and that process was coupled tongue and gums (25). Tongue lesions may be associated with
with TNF-α production (35, 36). TNF-α is an inflammatory the increasing activity of viral events on the epithelial mucosa
cytokine produced by macrophages/monocytes during acute of the tongue (39). On the other hand, immune suppression
inflammation and is responsible for a diverse range of signaling can lead to the harboring of opportunistic pathogens like
events within cells, leading to cell necrosis or apoptosis Candida albicans, which can lead to the above observed tongue
(37). These data suggest that cellular signals triggered by the lesions (19). SARS- CoV-2 oral lesions healed between 3
interaction of SARS-CoV with ACE2 are positively involved in and 28 days after they appeared. COVID-19-induced oro-
viral entry but lead to tissue damage. The presence of high ACE2 mucosal lesions can be treated with mouthwashes, topical or
expression in the alveolar tissues, oropharyngeal mucosal cells, systemic corticosteroids, systemic antibiotics and antivirals
gastrointestinal tract, kidneys and endothelial cells, including oral (39, 40). Increasing evidences are suggested that the antiseptic
tissues, indicated that those organs with high ACE2-expressing mouthwashes such as chlorhexidine, sodium hypochlorite and
cells should be considered to be potential high risk sites for povidone-iodine found to be effective in reducing the SARS-
SARS-CoV-2 (21, 32). CoV-2 viral load in the oral cavity and can be prescribed to
patients with mucosal lesions as first line of therapy (43, 44).
ORAL MANIFESTATION OF COVID-19 The topical or systemic corticosteroids, systemic antibacterial
and antiviral needs to be prescribed according to the individual
The pathology of viral infections is often associated with either patient needs. Multidisciplinary team approach is important
cellular destruction due to viral invasion or the consequence when prescribing or continuing systemic corticosteroids,

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Atukorallaya and Ratnayake Oral Health and COVID-19

antibiotics or antivirals to COVID-19-induced oro-mucosal females and loss of smell is associated with a loss of taste most of
lesions (39). the time (51, 53).
Still, there are a lack of data on a specific loss of different
tastants (flavors) (54). In a web-based questionnaire study (n =
COVID-19 INDUCED TASTE AND SMELL 128), 67 patients (52%) reported changes in taste sensation. Fifty-
LOSS two patients reported a change in their spicy taste perception,
54 in salty taste, 53 in sour taste, and 61 in sweet taste. In
Taste is a special sensation of the human oral mucosa which plays a comparison between men and women, COVID-19 induce
a vital role in the identification of nutrients and regulation of taste changes and changes in taste subgroups were found to be
food intake. Humans are capable of detecting five basic tastes: common among women, but this needs further investigations
sweet, sour, salt, bitter and umami. Tastes stimulate specialized (55, 56). A possible reason for the loss of taste in COVID-19
cells known as taste receptor cells (TRCs), which contain taste might be due to the increasing number of ACE-2 receptors on
signal transduction proteins. Sour and salty tastes modulate the tongue keratinocytes and the keratinocyte cell death and
the function of TRCs by the direct activation of specialized slough production can block taste buds which can adversely
membrane channels (45, 46). In contrast, sweet, bitter and affect taste perception (53, 57). However, the presence of ACE-
umami taste transduction is mediated through the G protein- 2 receptor activity on taste receptor cells is unknown at present,
coupled receptor (GPCR) signaling pathway (47). TRCs are hence the specific role of SARS-CoV-2 on specific taste bud
locally organized as taste buds (TBs) which are located in the cells (receptor cells and supportive cells) needs to be further
dorsum of the tongue and extra oral taste buds can be found investigated (57). It has been shown that GPCR can be found in
in the tonsils and oropharynx (Figure 1A). TBs are made of a diverse range of body tissues, not only in the oral cavity but
receptor cells, support cells and are innervated by branches of the in the lung epithelial cells, blood brain barrier and blood vessels
VII (facial), IX (glossopharyngeal), and X (vagal) cranial nerves. (58). It will be interesting to see the specific role of SARS-CoV-2
Taste information is relayed to the brain and its recognition elicits and GPCR interactions in terms of COVID-19 pathogenesis. On
behavioral responses to the food (48, 49). True loss of taste is the other hand, COVID-19 induces salivary gland dysfunction,
extremely rare, and it is usually preceded by the inability to which leads to dry mouth, and can result in the malfunctioning of
perceive the odor of food due to olfactory dysfunction or the taste perception (59). Treatment with artificial saliva can improve
deficiency of saliva to dissolve food molecules to get into the taste the xerostomia-induced taste loss (60). Quantitative smell testing
receptors (25, 50). demonstrates that decreased smell function is a major marker
Smells or odorants reach the olfactory epithelium, which of SARS-CoV-2 infection, and suggests the possibility that smell
covers the cribiform plate and the upper part of the nasal testing may help, in some cases, to identify COVID-19 patients in
septum and the middle/upper turbinates and dissolve in the need of early treatment or quarantine (61). Song et al. found that
mucus layer, binding/activating olfactory receptors (Figure 1A). a loss of taste was more frequent (21%) than a loss of smell (11%)
Up to 30 million receptor neurons, which express up to 350 in hospitalized patients, with the loss of taste but not smell being
different olfactory receptors, can be found in the olfactory associated with severe COVID-19 (62). Most patients recovered
epithelium. A complex combinatorial coding, by which each their smell and taste dysfunctions within 2 weeks (50, 62).
odorant ligand may be recognized by an olfactory receptor Overall, there is no real evidence for any specific
combination, enables humans to detect billions of different pharmacological option for the post-viral loss of smell including
odors. Olfactory information, which is processed and integrated COVID-19. Some studies report an improvement in olfactory
in the olfactory bulb, is then projected onto the primary function following topical or systemic corticosteroid therapy
olfactory centers such as the limbic system (emotions) and the (50, 63). Olfactory training is the only current evidence-based
hypothalamus (memory), and is finally projected to the olfactory therapeutic option for post-viral olfactory loss, with COVID-19
cortex, where humans acquire the consciousness of smelling positive patients reporting an improvement in smell (45.6%) and
(50, 51). Smell loss in respiratory infections are multifactorial taste (46.1%) at the time of the survey; in 90.6%, this was within
and are caused by a combination of the mechanical obstruction 2 weeks of infection (64). Over 90% of COVID-19 patients with
of odorant transmission in the olfactory cleft due to mucosal a loss of smell may recover that sense within the first month,
type 2 inflammation (oedema or nasal polyps), leading to and olfactory training is strongly recommended if smell has not
shedding, and/or degeneration of the olfactory epithelium and recovered after that period of time, but can be started earlier (65).
the reduction or loss of the sense of smell (51).
The SARS- CoV-2 infection associated sudden loss of taste
and smell was reported in several countries in early March, with ROLE OF SALIVA IN COVID-19
the rapid increase in COVID-19 patient numbers. Interestingly, PATHOGENICITY AND DISEASE
a series of sporadic cases, predominantly in health care workers, DIAGNOSIS
reporting a sudden, severe, and sometimes isolated loss of smell
and/or taste was reported in different countries (50, 52). Nasal Human saliva is a unique body fluid of the oral cavity. It is
congestion was found to be the driving factor for the loss of smell. a hypotonic solution of salivary acini, gingival crevicular fluid
It is possible that damage to the olfactory neuroepithelium can and oral mucosal exudates (66). Approximately 90% of saliva
cause defects in smell detection. Loss of smell is common among is secreted from the salivary glands; the major glands include

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Atukorallaya and Ratnayake Oral Health and COVID-19

TABLE 2 | Articles related to COVID-19 and dentistry.

Country Study overview Article type References

Italy Prevention of spread of SARS-CO-V-2 Review (72)

Italy Symptoms/signs, protective measures, awareness, and perception levels Questionnaire survey (73)
regarding COVID-19 among dentists in Lombardy, Italy
China COVID-19 and management protocols for dental practitioners and students Review (74)
Italy Prevention of COVID-19 in Pediatric dentistry Review (75)
Brazil Oral Manifestations in Patients with COVID-19 A living systematic review (76)
Italy Infection control in Dentistry Review (77)
Italy Oral manifestations of COVID-19 A narrative review (78)
Spain Oral lesions of COVID-19 Cross sectional study (79)
Multicenter study Endodontic emergency management by endodontists and general dental Online survey using questionnaire (80)
practitioners in COVID-19 times
USA Epidemiology, symptoms, and routes of transmission of COVID-19 Review (81)
India Safety operative protocols Commentary (82)
France Salivary and Nasal Detection of the SARS-CoV-2 Virus After Antiviral Mouth Randomized control trial (83)
rinses
Brazil Mouth wash reducing viral load of COVID-19 Systematic review (84)
Nigeria Impact on orthodontic patients Online questionnaire cross-sectional descriptive study (85)
India Appropriate orthodontic appliances during the COVID-19 pandemic Scoping review (86)

the parotid glands, submandibular glands and sublingual glands the subjective complaint of oral dryness, while salivary gland
(66). The salivary glands are highly vascular structures, where hypofunction is an objective matter characterized by reduced
there is a constant exchange of substances. A normal person salivary flow (70, 71). In SARS-CoV infections, xerostomia
produces 600 mL of saliva per day. It is mainly composed of could be aggravated by impaired nasal breathing due to nasal
water (94–99%), with organic molecules accounting for ∼0.5% congestion and rhinorrhea, where the oral breathing increase
and inorganic molecules for 0.2% (66). It has the functions of and it can impaired salivary gland function and xerostomia
lubricating the oral mucosa, digesting food, and cleaning and is secondary (25). Similar to COVID-19-induced oral mucosal
protecting the oral cavity, and is one of the most important lesions, pandemic-induced psychosocial factors have a greater
factors affecting homeostasis of the oral cavity. impact on normal salivary gland function and quantitative
Viral infections are often associated with the infection induced secretions (25, 59).
inflammation of the salivary gland (22). Saliva based biomarkers The saliva-based COVID-19 diagnosis is getting increased
are useful in diagnosis of several viral infections such as hepatitis attention for several important reasons. First, saliva specimens
A virus, hepatitis B virus, hepatitis C virus, HIV-1, measles can be easily obtained, by asking patents to spit into a container,
virus, rubella virus, and mumps virus (66). Several routes of which is not an invasive procedure and minimizes the chance
SARS-CoV-2 viral entry into the saliva have being suggested. of exposing health care workers to the highly infectious SARS-
There is direct entry to the oral cavity from upper and lower CoV-2 virus; it is also ideal for testing the elderly vulnerable
respiratory tract secretions, while circulatory viruses in the blood population, pediatric patients and community settings, where
enter the gingival crevicular fluid. Studies reported a high yield large sample collection is needed (Table 2) (87). There is
of virus particles in the gingival sulcus and crevicular fluid and a 92% positive rate of SARS-CoV-2 in saliva compared to
are suspected to provide favorable conditions for virus replication nasopharyngeal aspirate and live virus can be successfully
and maintenance (32). Moreover, SARS-CoV-2 salivary gland cultivated through saliva samples, highlighting the value of saliva
infections can produce large amounts of viruses in the salivary in the diagnosis of COVID-19 (88). As discussed previously,
gland tissues and release them into the secretions (67). Studies the early detection of SARS-CoV-2 in the saliva can be vital
performed on rhesus macaques found that there is a rapid in diagnosing COVID-19 patients before respiratory symptoms
infection in the salivary gland epithelial cells by SARS-CoV, appear, which greatly aids in controlling public health measures
suggesting salivary glands as very early proliferating sites for such as the quarantine process (20, 88, 89).
coronaviruses (68). Hence, increased ACE-2 expression in minor
salivary glands compared to the lungs suggestive of salivary
glands as an early target organ and saliva can be a vital source FUTURE PERSPECTIVES WITH REGARD
in the early diagnosis of disease before the respiratory symptoms TO THE ORAL HEALTH PROFESSION
appear (20, 31, 68).
In COVID-19, the impaired salivary gland secretions are often On March 11th 2020, the World Health Organization (WHO)
associated with xerostomia and taste loss (69). Xerostomia is declared COVID-19 to be a global pandemic. As of the 20th

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Atukorallaya and Ratnayake Oral Health and COVID-19

January 2021, 96,866,468 cases had been reported globally, with and negative in screening questionnaire and no fever) (2) Triage
20,72,466 deaths. The first cases of COVID-19 were seen in positive (positive screening questionnaire and /or fever) (3)
Canada on February 10th 2020, and there have since been confirmed COVID-19 cases. However, it is extremely important
723,908 cases and 18,421 deaths (90). The current public health to take all the necessary precautions when treating the first
regulations to prevent the spread of this virus have been based category (82). The ability to undertake robust patient screening
on the modes of transmission. Following the strict global (WHO) would facilitate the avoidance of COVID-19 transmission in
and Canadian public health guidelines was found to be effective dental clinics. A non-invasive rapid screening test would be
in preventing the spread of COVID-19 (91, 92). Several excellent of great help to identify positive cases that warrant immediate
research and review articles have already been published on the quarantine or transfer to special clinic for further treatment
impact of COVID-19 on clinical dentistry and the relevance of (88, 93). Current research are focusing on developing biomarkers
the oral cavity in SARS-CoV-2 infection (Table 2) (24, 72, 93). for early detection, treatment and prevention of COVID-19. In
The dental regulatory authorities quickly adapted new rules the oral health care settings saliva and mucosal epithelial cells
and regulations with regard to patient care and prevention of are good candidates to develop the biomarkers to identify the
the spread of SARS-CoV-2 (72, 93). Among the health care asymptomatic carriers (Table 2).
professions, dental professionals have a high risk of making Given the higher viral loads in the oral cavity, it is essential
contact with diseased individuals and spreading the disease in to use personal protective equipment (PPE). Protective goggles
nosocomial settings. or face shields, masks, gloves, and caps should be regularly
The American Dental Association has developed guidelines to worn, discarded or properly disinfected between each patient.
the patient care during COVID-19 pandemic (94). The dental Salivary aerosols and blood need to be protected against to
treatments are divided into the urgent/emergency care and reduce the risk of infection with COVID-19 (96). The use of
routine/elective procedures. The dental emergencies which needs rubber dams can significantly minimize the production of saliva-
immediate medical attention includes life threatening conditions contaminated splatters, droplets and aerosols, particularly when
uncontrolled bleeding, swelling and fractures which compromise high-speed dental hand pieces and ultrasonic devices are used.
patient’s airway. Urgent dental care should focus on minimizing The application of a rubber dam can significantly reduce airborne
pain, reduce or control infection, and reduce the burden on particles in an ∼3 foot diameter of the operational field by
emergency departments (94). Other than that suture removal, 70% (97). High-speed dental hand pieces without anti-retraction
denture adjustment, replacing fillings to alleviate pain and valves may aspirate and expel debris and fluids during dental
snipping or adjusting orthodontic appliances to prevent trauma procedures; also, the hand instruments used during general
also considered as urgent dental care. The non-urgent routine dental procedures produce a significant amount of aerosol
procedures include initial dental visits, routine dental cleaning spread (72). Good ventilation, regular and thorough surface
and preventive therapies, aesthetic dental procedures, and disinfection before and after procedures with alcohol or chlorine
extraction of asymptomatic teeth and orthodontic procedures and the proper handling of saliva-containing waste are critical
(94). The ultimate goal is to avoid unnecessary contacts and in preventing the spread of COVID-19 (96). Recent studies
minimize the contact to prevent the further spread of the shows that mouth rinses can reduce the SARS-CoV-2 virus load
virus in the dental care settings. The COVID-19 pandemic (98). Marui et al. showed that pre-procedural mouth rinses can
opens up a variety of innovative technologies for meetings significantly reduce microbial load in dental aerosols (99). Also,
such as teleconferencing, video calls, and patient photographs. the use of pre-procedural mouth rinses before dental treatment
Brian & Weintraub discuss use of communication media can be advantageous during the pandemic (100).
such as Teledentistry to educate and consult patients during We are too early to predict the post-pandemic effects of
the pandemic period, where it would greatly facilitate the COVID-19. However, COVID-19 has a wide range of impacts
prevention of unnecessary dental visits for conditions which on mental health, which can have a negative effect on the
can be temporarily alleviated at home or postponed for a oral health of any given community; in particular, a greater
later date (93). The patients with underlying health conditions impact can be seen in vulnerable populations such as people
such as diabetes, cancer, cardiovascular diseases (CVD) and with low socioeconomic status who lack access to proper health
hypertension are more susceptible to developing COVID-19 thus care. On the other hand, this is a challenging time for dental
needs special attention. For instance, diabetes is a metabolic health professionals and it could affect their psychological status,
disorder which adversely affect the periodontal health. The which can adversely affect their overall productivity. For instance,
periodontal disease (PD) is a chronic inflammatory disease which adopting new techniques to minimize the spread of disease,
induce increased cytokine production and the disease severity and reduced wages as this is associated with a decline in
found to be increased with COVID-19 infection (95). It is per capita dental visits (93). The timely vaccination of health
important to identify patients with underlying comorbidities and care professionals and the vulnerable population is now a
advise them on maintaining good oral hygiene to prevent the strategic priority for the prevention of COVID-19 in many
further progression of existing PD (Table 2). countries. Dai and Gao in their progressive article discussed
Dental health care personals should be trained to be about the different vaccine candidates against SARS-CoV-2 (i.e.,
familiar with COVID-19 related signs and symptoms. The triage Inactivated virus vaccines, virus like particle or nanoparticle
screening is a successful method to identify and separate out viruses, protein subunit vaccines, virus-vectored vaccines, DNA
patients into three categories: (1) Triage negative (asymptomatic and mRNA vaccines and live attenuated vaccines) and compare

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Atukorallaya and Ratnayake Oral Health and COVID-19

their effectiveness against COVID-19 (101). The world largest and prepared to fight future pandemics. Specifically, scientific
vaccination campaign begins with the BioNTech/Pfizer, and knowledge gained from this pandemic can be useful in designing
Moderna/NIAID vaccines and Oxford-AstraZenca’s is now public healthcare protocols to prevent future pandemics and
authorized and added to this mass prevention battle against vaccines, and therapeutic treatment research will be invaluable
COVID-19. However, the immunization programs needs further in patient management in any virulent coronavirus infections.
investigations for their effectiveness against the novel variants of
SARS-CoV-2 (101, 102). Further studies need to be performed to AUTHOR CONTRIBUTIONS
identify the pathogenicity of SARS-CoV-2 on specific epithelial
organs of the oral cavity and its effect on oral health. Salivary DSA and RKR contributed to the conception and critically
research can be directed toward designing rapid identification revised the manuscript. Both authors contributed to the article
test kits as a chair-side test prior to any dental procedures in order and approved the submitted version.
to diagnose SARS-CoV-2 carriers. The use of corticosteroids,
antivirals and antibiotics to treat the oral mucosal lesions of ACKNOWLEDGMENTS
COVID-19 needs to be studied further using large samples
in different demographic settings. The ongoing COVID-19 We would like to acknowledge University of Manitoba for
pandemic is an eye-opener to all of mankind to be vigilant supporting the research in the Atukorale laboratory.

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coronavirus disease 2019 pandemic on orthodontic patients and their publication in this journal is cited, in accordance with accepted academic practice.
attitude to orthodontic treatment. Am J Orthod Dentofacial Orthop. (2021). No use, distribution or reproduction is permitted which does not comply with these
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